Provider Demographics
NPI:1023568961
Name:FAGAN, TERESE (LCSW)
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 TOLLAND TPKE UNIT 258
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-1679
Mailing Address - Country:US
Mailing Address - Phone:860-778-3304
Mailing Address - Fax:
Practice Address - Street 1:45 S MAIN ST
Practice Address - Street 2:SUITE 107
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2441
Practice Address - Country:US
Practice Address - Phone:860-778-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical